Prevention of dehydration in hospital patients

John A, Tierce R, Zheng X, Zhou C, Noval MG, O'Keeffe A, Podkowik M, Gonzales S, Inglima K, Desvignes L, Hochman SE, Stapleford KA, Thorpe LE, Pironti A, Shopsin B, Cadwell K, Dittmann M, Torres VJ. SARS-CoV-2 infection predisposes patients to coinfection with Staphylococcus aureus

Severe COVID-19 has been associated with coinfections with bacterial and fungal pathogens. Notably, patients with COVID-19 who develop Staphylococcus aureus bacteremia exhibit higher rates of mortality than those infected with either pathogen alone. To understand this clinical scenario, we collected and examined S. aureus blood and respiratory isolates from a hospital in New York City during the early phase of the pandemic from both SARS-CoV-2+ and SARS-CoV-2- patients. Whole genome sequencing of these S. aureus isolates revealed broad phylogenetic diversity in both patient groups, suggesting that SARS-CoV-2 coinfection was not associated with a particular S. aureus lineage. Phenotypic characterization of the contemporary collection of S. aureus isolates from SARS-CoV-2+ and SARS-CoV-2- patients revealed no notable differences in several virulence traits examined. However, we noted a trend toward overrepresentation of S. aureus bloodstream strains with low cytotoxicity in the SARS-CoV-2+ group. We observed that patients coinfected with SARS-CoV-2 and S. aureus were more likely to die during the acute phase of infection when the coinfecting S. aureus strain exhibited high or low cytotoxicity. To further investigate the relationship between SARS-CoV-2 and S. aureus infections, we developed a murine coinfection model. These studies revealed that infection with SARS-CoV-2 renders mice susceptible to subsequent superinfection with low cytotoxicity S. aureus. Thus, SARS-CoV-2 infection sensitizes the host to coinfections, including S. aureus isolates with low intrinsic virulence.

IMPORTANCE

The COVID-19 pandemic has had an enormous impact on healthcare across the globe. Patients who were severely infected with SARS-CoV-2, the virus causing COVID-19, sometimes became infected with other pathogens, which is termed coinfection. If the coinfecting pathogen is the bacterium Staphylococcus aureus, there is an increased risk of patient death. We collected S. aureus strains that coinfected patients with SARS-CoV-2 to study the disease outcome caused by the interaction of these two important pathogens. We found that both in patients and in mice, coinfection with an S. aureus strain lacking toxicity resulted in more severe disease during the early phase of infection, compared with infection with either pathogen alone. Thus, SARS-CoV-2 infection can directly increase the severity of S. aureus infection.

Dietary and water restriction leads to increased susceptibility to antimicrobial resistant pathogens

Dehydration and malnutrition are common and often underdiagnosed in hospital settings. Multidrug-resistant bacterial infections result in more than 35,000 deaths a year in nosocomial patients. The effect of temporal dietary and water restriction (DWR) on susceptibility to multidrug-resistant pathogens is unknown. We report that DWR markedly increased susceptibility to systemic infection by ESKAPE pathogens. Using a murine bloodstream model of methicillin-resistant Staphylococcus aureus infection, we show that DWR leads to significantly increased mortality and morbidity. DWR causes increased bacterial burden, severe pathology, and increased numbers of phagocytes in the kidney. DWR appears to alter the functionality of these phagocytes and is therefore unable to control infection. Mechanistically, we show that DWR impairs the ability of macrophages to phagocytose multiple bacterial pathogens and efferocytose apoptotic neutrophils. Together, this work highlights the crucial impact that diet and hydration play in protecting against infection.

Comparison of IVC diameter ratio, BUN/creatinine ratio and BUN/albumin ratio for risk prediction in emergency department patients

INTRODUCTION

Early prediction of patients' prognosis in the emergency department (ED) is important. Patients' conditions such as dehydration help predict prognosis. The ratio of serum blood urea nitrogen to creatinine (BUN/Cr ratio) and inferior vena cava (IVC) diameter is often used to determine dehydration. Also, serum albumin levels reflect nutritional conditions such as dehydration. In this study, we evaluated the performance of BUN/Cr ratio, IVC diameter ratio, and BUN/Albumin ratio as predictive markers for in-hospital mortality and ICU admission among various diseases in ED.

MATERIAL AND METHODS

This retrospective cohort study utilized data from patients who had abdominal and pelvic computed tomography (APCT) performed at our institution from 2015 to 2018. The measurement of IVC diameter from computed tomography, the BUN/Cr ratio, and the BUN/Albumin ratio were calculated. Differences in the performance among the BUN/Cr ratio, the IVC diameter ratio, and the BUN/Albumin ratio for predicting outcomes were evaluated by the area under the receiver operating characteristic (AUROC) curve.

RESULTS

A total of 914 patients were enrolled and 78 patients (8.5%) were admitted to the ICU, and 71 patients (7.8%) died during the clinical process. Multivariate logistic regression showed that only the BUN/Albumin ratio was a significant predictor of inhospital mortality and ICU admission.

CONCLUSION

Among dehydration markers the BUN/Albumin ratio is a simple and useful tool for predicting the outcomes of patients visiting the ED.

Care complexity individual factors associated with adverse events and in-hospital mortality

Introduction

Measuring the impact of care complexity on health outcomes, based on psychosocial, biological and environmental circumstances, is important in order to detect predictors of early deterioration of inpatients. We aimed to identify care complexity individual factors associated with selected adverse events and in-hospital mortality.

Methods

A multicenter, case-control study was carried out at eight public hospitals in Catalonia, Spain, from January 1, 2016 to December 31, 2017. All adult patients admitted to a ward or a step-down unit were evaluated. Patients were divided into the following groups based on the presence or absence of three adverse events (pressure ulcers, falls or aspiration pneumonia) and in-hospital mortality. The 28 care complexity individual factors were classified in five domains (developmental, mental-cognitive, psycho-emotional, sociocultural and comorbidity/complications). Adverse events and complexity factors were retrospectively reviewed by consulting patients’ electronic health records. Multivariate logistic analysis was performed to identify factors associated with an adverse event and in-hospital mortality.

Results

A total of 183,677 adult admissions were studied. Of these, 3,973 (2.2%) patients experienced an adverse event during hospitalization (1,673 [0.9%] pressure ulcers; 1,217 [0.7%] falls and 1,236 [0.7%] aspiration pneumonia). In-hospital mortality was recorded in 3,996 patients (2.2%). After adjustment for potential confounders, the risk factors independently associated with both adverse events and in-hospital mortality were: mental status impairments, impaired adaptation, lack of caregiver support, old age, major chronic disease, hemodynamic instability, communication disorders, urinary or fecal incontinence, vascular fragility, extreme weight, uncontrolled pain, male sex, length of stay and admission to a medical ward. High-tech hospital admission was associated with an increased risk of adverse events and a reduced risk of in-hospital mortality. The area under the ROC curve for both outcomes was > 0.75 (95% IC: 0.78–0.83).

Conclusions

Several care complexity individual factors were associated with adverse events and in-hospital mortality. Prior identification of complexity factors may have an important effect on the early detection of acute deterioration and on the prevention of poor outcomes.

Advanced Sensing and Human Activity Recognition in Early Intervention and Rehabilitation of Elderly People

Ageing is associated with a decline in physical activity and a decrease in the ability to perform activities of daily living, affecting physical and mental health. Elderly people or patients could be supported by a human activity recognition (HAR) system that monitors their activity patterns and intervenes in case of change in behavior or a critical event has occurred. A HAR system could enable these people to have a more independent life.

In our approach, we apply machine learning methods from the field of human activity recognition (HAR) to detect human activities. These algorithmic methods need a large database with structured datasets that contain human activities. Compared to existing data recording procedures for creating HAR datasets, we present a novel approach, since our target group comprises of elderly and diseased people, who do not possess the same physical condition as young and healthy persons.

Since our targeted HAR system aims at supporting elderly and diseased people, we focus on daily activities, especially those to which clinical relevance in attributed, like hygiene activities, nutritional activities or lying positions. Therefore, we propose a methodology for capturing data with elderly and diseased people within a hospital under realistic conditions using wearable and ambient sensors. We describe how this approach is first tested with healthy people in a laboratory environment and then transferred to elderly people and patients in a hospital environment.

We also describe the implementation of an activity recognition chain (ARC) that is commonly used to analyse human activity data by means of machine learning methods and aims to detect activity patterns. Finally, the results obtained so far are presented and discussed as well as remaining problems that should be addressed in future research.

Strategies to prevent dehydration in older people with dementia: a literature review

Dehydration is prevalent in hospitalised older people and residents in care homes, and older people with dementia are particularly at risk. A literature review was conducted to determine the evidence-based interventions used to prevent and manage dehydration in older people with dementia. Three databases were searched for relevant literature: Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, and MEDLINE, alongside hand-searching. In-depth reading of the 12 studies included in this literature review was undertaken. Five themes were identified in relation to the hydration of older people: physical and social environment; staff communication strategies; access to drinks; drinking vessels; and individual preferences. The evidence suggests that dehydration in older people with dementia is an ongoing concern that needs to be addressed. There is evidence supporting the use of essential nursing interventions to improve hydration, such as coloured cups and verbal prompts, but less is known about the barriers preventing nurses from implementing these evidence-based interventions.

A multicentre prospective audit of bedside hydration in hospital

INTRODUCTION

access to water at the bedside is a cornerstone of patient care. Among bedbound inpatients, water within reach at the bedside is a basic human dignity and one that ought not to be neglected.

AIM

the authors sought to identify the extent to which accessible hydration facilities were provided to a bedbound inpatient population.

METHODS

a cross-sectional, point-prevalent audit of hospitalised medical inpatients across five centres was conducted. Data were collected between meal times and noted baseline demographics and admission details, adequacy of oral hydration provision at the bedside and, where provision was inadequate, factors associated with this.

RESULTS

across a total surveyed patient population of 559 we identified 138 patients who were bedbound. Among these bedbound patients, 6% (n=8) had no water provided at the bedside. However, 7 of these were deemed to be unable to swallow safely. In total, 44 (32%) of the 138 bedbound patients were unable to reach the water at their bedside; 18 of these patients would have been able to drink for themselves had the water been in reach.

CONCLUSION

there is significant room for improvement in ensuring patients who are immobile are able to reach drinking apparatus at the bedside. In the five centres surveyed, approximately one in five bedbound patients with no contraindication are unable to reach an essential means of hydration.

'I've never drunk very much water and I still don't, and I see no reason to do so': a qualitative study of the views of community-dwelling older people and carers on hydration in later life

Background

dehydration is associated with significant adverse outcomes in older people despite being largely preventable and treatable. Little research has focused on the views of community-dwelling older people on hydration, healthy drinking and the perceived importance of drinking well in later life.

Objectives

to understand community-dwelling older people and informal carers’ views on hydration in later life and how older people can be supported to drink well.

Methods

qualitative study using interviews and a focus group exploring hydration and nutrition in later life (24 older people at risk of malnutrition and dehydration, 9 informal carers) and thematic analysis.

Results

this article presents the findings on hydration alone. Four themes are presented: perceptions of healthy drinking, barriers to and facilitators of drinking in later life and supporting older people to drink well. The perceived importance of adequate hydration in later life was polarised. Concerns about urinary incontinence and knowledge gaps were significant barriers. Consideration of individual taste preference and functional capacity acted as facilitators. Distinct habitual drinking patterns with medications and meals exist within individuals. Many relied on thirst at other times or when fluid demands are greater (such as hot weather), a known unreliable prompt in later life.

Conclusions

older people could be supported to drink well by building upon existing habitual drinking patterns. Primary care and public health should consider individual barriers, facilitators and tailored education. A multidisciplinary approach to promote hydration should be incorporated into care for older people with more complex needs.